Monday, March 30, 2009

President Obama has created a unique opportunity to transform the health system. Health care consumers, women and public health advocates know we need an Equitable, Quality, Universal, Affordable health system. But special interests in D.C. have other ideas. Sign up to let the President and Congress know we need a publicly financed, publicly administered plan like Medicare. We'll send the message to them by April 6, when the White House health care forum convenes in Los Angeles. Ask your friends and colleagues to sign too!

Dear President Obama,Thank you for taking leadership towards winning national health reform. We want to help. We are asking you and our members of Congress:1. Give us an American solution we know and trust. Expand Medicare to make sure everyone in America is covered by this popular, affordable, publicly financed and publicly administered program.2. We have learned a lot since the last time. Special interests cant scare us about government-run health care, and losing our choices. Too many of us have had to struggle at our sickest for the care we deserve, even when we were insured. We know that everyone on Medicare can choose our own doctor and hospital, and we do not lose coverage when we get sick. That is the choice we care about.3. Expand Medicare benefits to address all our needs for preventive, acute, and long-term care, including reproductive health services, prescription drugs, dental, mental health, vision, and alternative and complementary medicine.4. Stick with your plans to let our doctors and nurses know which treatments are most effective, and encouraging team practices. We all deserve the best quality care.5. Thank you for investing in public health. It is time to make sure all our social and economic policies make us healthier, from the environment to education, from the dinner table to our transportation systems. We know that keeping the coverage we have is not a real choice for many in todays economy. Covering everyone under a publicly-financed, publicly- administered program like Medicare slashes administrative costs from 30% to 3% of the health care dollar, and saves money for individuals, employers, and the government.

Thursday, March 5, 2009

The White House health care summit started out inspiringly. Single payer advocates organized their way into the room. The President had originally refused to invite Rep. John Conyers, the lead co-sponsor of the House’s Medicare for All bill, HR 676. The bill would virtually eliminate the private insurance industry, something the President had taken off the table in a nod to that industry’s power and past political clout. But Physicians for a National Health Program and other activists generated massive phone calls in protest, and threatened to demonstrate in front of the proceedings. Rep. Conyers was invited in, along with PNHP President Oliver Fein, MD.

It was a bracing early victory.

Compared with last week’s economic summit, the health care event had the aura of a classroom political science exercise rather than a call to address a pressing financial and humanitarian crisis, with causes and effects, as well as known – if politically difficult - solutions.

Government officials have spent months excoriating the malfeasance of corporate executives and lax regulators who brought the economy to rack and ruin. And then turned around and given them more bucks. The economic summit ended on a forceful note: Fix the health care system, or we doom prospects for economic recovery.

But once at the health care discussion, no actor was excluded from a civil hearing (including, ultimately, single payer). The insurance industry, pharmaceutical manufacturers, hospitals, employers, doctors and nurses, and national leaders of health care consumer groups flanked members of Congress to describe the crises in access, costs and quality. They broke into several groups to talk about the issues for about an hour and a half, then reconvened to chat further with the President.

In the group televised on C-Span, and moderated by Melody Barnes and Bob Kocher, members of Congress provided the most grounded and the most pointed comments in the face of nearly surreal assertions by others on the panel. Business Roundtable Chair Ken Powell, CEO of General Mills, a processed food giant that has lost 30% of its stock value since September and experienced its share of layoffs, waxed eloquent about how employers are firmly committed to continuing to play a central role in providing health benefits to their employees. They love doing it and by golly they feel good about how good they are at doing it! They’re offering wellness programs that make a real difference in their employee’s lives. He didn’t exactly address how we should deal with the 40% of employers who offer no benefits at all (a detail Rep. Rob Andrews of New Jersey pointed out). In other words: they don’t want the government to do it.

Blue Cross Blue Shield likewise marveled at its own wellness programs. Though they did agree it was time for reform. (Probably need to do something about those pesky pre-existing condition exclusions.) As long as everyone is required to pay into the system. Well actually, to pay them. They didn’t really see the need for a competing public insurance plan.

It was up to Rep. Allyson Schwartz to mention that there are no hospitals left in northeast Philadelphia that deliver babies. She also mentioned the newborn baby who had jaundice for the first five days of life and was denied insurance coverage just about straight out of the womb, because of the risk that she might someday develop liver disease. Rep. Baron Hill of Indiana confessed that 60% of his generally conservative constituency thought that the government should take over the health care system, though they were divided about exactly how. A somewhat ambivalent Jan Schakowsky soldiered on in allegiance to an Obama-like hybrid plan, but stuck up for Medicare as a program popular with its beneficiaries, and well run. Republican Jo Ann Emerson spoke movingly about the failures of access in rural areas, and nodded to Sen. Byron Dorgan who continues to team up with her to propose legal reimportation of affordable drugs. (PhRMA CEO Billy Tauzin was in a different breakout group.)

Rep. Earl Pomeroy and Sens. Whitehouse and Hatch bemoaned the perverse incentives and poor outcomes of the delivery system.

But John Dingell took the cake. In a few sentences, he recalled his father introducing the first single payer bill in the U.S. Congress in 1943, though he was beaten to the punch by “those socialists, Edward VII of England and Bismarck in Germany.” He agreed with his colleagues who suggested, in a masterful stroke of understatement, that the current system is too administratively cumbersome and should be simplified.

I have yet to watch the rest of the discussions online, including the one attended by the ever-eloquent Dr. Fein. The group of Congress members I watched clearly reveres the President, and no one’s breaking ranks just yet. And they all knew they were on TV. But are they ready to contract out the job of controlling health care costs to the same cast of characters that dug us into this hole in the first place? One makes predictions about health care politics only at great peril. So for now the best answer is, maybe. And maybe not.

The White House Forum on health reform will include two single-payer supporters: Rep. John Conyers, sponsor of HR 676/Medicare for All, and Dr. Oliver Fein, President of Physicians for a National Health Program. Advocates nationwide called the White House to protest the exclusion of the single-payer perspective - and the WH responded. Watch C-Span starting at 1 p.m. EST on March 5, and watch this Blog for comments.

Extend and expand health coverage and access.■ Children – Reauthorize SCHIP - Enacted■ Expand SCHIP to cover ages 0 – 25.■ Medicare – Expand coverage to start at age 50• Eliminate the 24-month wait for Medicare benefits for persons with qualifying disabilities.■ Medicaid – Increase enrollment and access:• Increase the federal match in Medicaid funding and minimize cost shifting to patients.• End categorical eligibility. Extend eligibility to everyone living in poverty, and to all uninsured recipients of unemployment compensation, as proposed by Sen. Baucus.• Simplify documentation and application requirements.• Increase transparency of the state waiver process that is eroding federal standards for Medicaid.■ Safety-net institutions: Increase funding for public hospitals, and for community and migrant health centers. Proposed in budget.

Improve the health of the nation■ Link action across government sectors (employment, housing, education, environment, commerce and trade, health) to address the social and economic conditions and policies that make people sick and produce health inequities: economic deprivation, discrimination, and adverse conditions at work, in the environment, and in communities. Make improving health and reducing health inequities a criterion for all government initiatives. - Tax proposals reduce income inequality(See report of the World Health Organization's Commission on the Social Determinants of Health: http://www.who.int/social_determinants/final_report/en/index.html)

Are Americans really happy with the status quo, and fearful of change?

Sen. Max Baucus' health proposal notes,

More than 70 percent of Americans rate our health care system as “fair” or “poor.”41 When asked whether our health system needs a complete overhaul, major repairs, or minor tinkering, 90 percent of Americans respond that the system should be “completely rebuilt” or that “fundamental changes” are needed.4.

He continues:

At the same time, those who currently have health coverage do not want to lose those benefits. Many people are satisfied with their personal providers or their current coverage and do not want to jeopardize those connections to the system.

Do people really care about their health plan? Avoiding disruption, yes, as Medicare could do. Warm and fuzzy about UnitedHealth? He doesn't provide evidence (or a citation - though I'm sure there is one; Celinda Lake's latest comes close).

Americans do not necessarily agree on how to achieve it (see Figure 1.5). Although a majority of respondents would support a mandate on employers to provide coverage, a “Medicare-for-all” single-payer option, or a mandate that all individuals purchase coverage, opposition to each of these options is also somewhat substantial. Moreover,some of this support erodes when respondents are asked whether they would be willing to have more government responsibility or higher taxes — though half of all surveyed in 2007 said they would support reform even under these circumstances.46 (2007 survey figures)

http://finance.senate.gov/healthreform2009/finalwhitepaper.pdf

These are pretty close odds and the numbers are 2 years old. Given that a Medicare for all option would undoubtedly work, and the other 2 options are iffy at best, does it make sense to just abandon the one that's workable? Conventional wisdom says yes; as it has in the many states that have tried it and failed. Admittedly, the federal government has greater authority to mandate employer contributions than do states, because of ERISA. Maybe this can work. Beats me how.

Reed Abelson's NY Times article (excerpts below) suggests that the private for-profit health insurance industry is increasingly vulnerable, financially and politically. It could lose 10 million enrollees this year, out of about 160 million currently, due to the economic downturn.

It confirms that for-profit health insurance companies provide little value and have relied on the tolerance of government to stay in business.

Aetna's $3 billion a year in profits outstrips the first year savings in the Obama budget directed towards health care reform: $2 billion.

The industry insists that proposals for reform require every individual to pay in, in return for expanding coverage: a direct subsidy to them (what is it that they do again...).

They oppose an expanded role for social insurance plans like Medicare. Medicare already requires that everyone pay in, and covers everyone who does. EQUAL Health and others propose lowering the eligibility age for Medicare to 50 immediately (http://www.centerforpolicyanalysis.org/id24.html).

To refresh their mission, they aim to manage patient care. (Didn't we try that already?) Don McCanne's summary of recent studies suggests that the insurance industry's efforts to create "medical homes" generally come down to adding a few phone calls from a nurse practitioner, and don't save money or improve outcomes. In contrast, a competing possibility would be "doctors forming more alliances to oversee care or hospitals joining forces with physicians" - a group that really could provide coordinated, continuous, patient-responsive primary care, well-documented to save money and improve outcomes. [But still would need a government-directed program to assure access & affordability.]

.....Almost every business in the country is feeling buffeted by the recession. But for health insurance companies, the bleak economy is only part of the problem: the changing of the guard in Washington is an equal if not more dangerous threat. Together, these forces could deal a body blow to a business model that was already teetering.

Health plans are losing millions of members who say they can no longer afford their products. Some big employers are becoming increasingly frustrated — and vocal — about how much they spend on health benefits. Smaller ones are being crushed by ever-rising health care costs. On top of that, the Republicans who pushed to expand the role of private players in the health care system have largely been replaced by Democrats who want to overhaul it.

.....The insurers are “as vulnerable politically as they have been in the last 10 to 15 years,” said Sheryl R. Skolnick, an analyst at CRT Capital Holdings in Stamford, Conn.

.....But the industry is also taking a very public role in voicing concern about some of the proposals being floated. In supporting legislation that would prevent the companies from refusing to cover people with existing medical conditions, the insurers have said the government must require everyone to buy insurance, subsidizing the cost for those who cannot afford it.

FOR private insurers, the more troubling specter in health care reform is an expansion of the Medicare program to those under 65. The program has lower expenses and generally pays much less for medical care than private insurers, so it would probably translate into a lower-cost plan for consumers. To help lead opposition to the idea, which they say puts them at an unfair disadvantage, insurers have joined with hospitals to argue that Medicare pays too little so that any expansion would significantly hurt providers.

But by acknowledging a need for a greater government role, the industry hopes it can persuade the president and Congress that it makes the most sense to work together. “Whatever we do has to be a public-private partnership,” said Mr. Williams, the Aetna C.E.O.

.....Politics aside, the weak economy has highlighted just how vulnerable insurers are to pricing themselves out of the market. The percentage of people who are commercially insured fell to about 68 percent last year from about 78 percent two decades ago, according to Matthew R. Borsch, an analyst at Goldman Sachs. The numbers do not include the elderly.

“The reason really comes down to affordability,” said Mr. Borsch, who predicts that the number of people who lose or drop their commercial coverage during the economic downturn could approach 10 million. “It looks like the pace of erosion is really accelerating.”

Both Aetna and UnitedHealth had double-digit declines in earnings last year, but both remain solidly profitable. Aetna earned $1.4 billion, down 24 percent, on sales of $31.6 billion, while UnitedHealth had net earnings of nearly $3 billion, down 36 percent, on revenue of $81.2 billion.

Insurers’ corporate customers have been increasingly critical of the value of their health coverage. I.B.M., for example, says the industry is not helping to provide care that is more cost-effective in helping their workers live longer and more productive lives. The insurers “don’t have a clue about providing what we really want to buy,” said Dr. Paul Grundy, the executive at I.B.M. who oversees its health care efforts.

The company’s current emphasis is on increasing its presence in Medicaid, where it expects to add roughly 400,000 new members this year.

In contrast, Aetna is betting more heavily that employers will continue to play a crucial role, providing coverage for a majority of Americans. Unlike much of the rest of the industry, the company is increasing the number of people enrolled in its commercial health plans, expecting this year to add roughly 1.3 million members, largely through its employer business.

Aetna says it believes it will be able to convince skeptical employers and government officials that it can, in fact, oversee a patient’s medical care to both save money and improve quality. No longer a company of just underwriters or claims handlers, Aetna has about 20 percent of its work force dedicated to information technology, including systems to flag doctors about potential problems in a patient’s care. Another 20 percent are clinicians, including nurses who help coach patients through a difficult illness.

Other possibilities include doctors forming more alliances to oversee care or hospitals joining forces with physicians — all to start competing with insurers.

Monday, March 2, 2009

President Obama’s Budget: Cheers for Health,Down Payment on Health Reform

February 27, 2009

President Obama is using his new budget as a bully pulpit for health care reform, an encouraging sign in itself that he will exert leadership to keep the issue moving. It supports critical programs that will make a difference for people’s health, including new initiatives in clinical care and public health, and programs that will reduce income inequality. But the budget is still in the “down payment” stage towards transformational health reform, that would cover the nation’s 47 million uninsured, and make the system affordable for the future.

The economic crisis demands that we get a grip on health care costs, which have grown twice as fast as wages. And lower costs can go hand in hand with better quality of care and universal coverage. The President’s proposals, as reflected in the budget, while headed in the right direction, don’t quite get there. The budget takes modest steps towards improving clinical care. And it reduces excessive payments to private health insurance plans in the Medicare Advantage program, where the federal government already has the greatest leverage. But it doesn’t take on wasteful practices by insurance companies in the private sector, a key driver of costs.

The President offers a new and complex program that might or might not work, creating a Medicare-like backup plan to cover the uninsured and possibly others. In the present dire economic circumstances, it would be quicker and more effective to expand who is covered under Medicare, Medicaid and other public programs. Only the public sector has the clout and resources to assure that everyone is covered, and to negotiate successfully with powerful health care interests, including drug companies and medical device companies. Medicare already has administrative costs licked, and is geared towards covering a large national population that uses lots of health care: the elderly and disabled. Medicare and Medicaid have been under attack, but Congress is moving forward to address problems with underfunding and privatization in Medicare, and eligibility issues in Medicaid. Ready legislation (H.R. 676, H.R. 193) describes in detail how we can move from here to there.

The Administration has carefully nurtured and encouraged the political will for reform. Pressure and support from the public will be essential to keep it moving on the right track.